The Person-Centered Journal, Volume 4, Issue 1, 1997
Printed in the U.S.A. All rights reserved.

THE PRIMARY PREVENTION OF PSYCHOSOCIAL DISORDERS:
A PERSON/CLIENT-CENTERED PERSPECTIVE

C. H. Patterson
University of North Carolina at Greensboro

Suzanne C. Hidore
Greensboro, North Carolina

ABSTRACT: Psychotherapy is the treatment for psychosocial disorders deriving from disturbed interpersonal relationships. The essence of psychotherapy is love, or agape. It is argued that it follows that love is the primary prevention of psychosocial disorders. Unconditional love in infancy and early childhood is necessary for the normal psychosocial development of all human beings. Steps to be taken for proactive intervention are included. Published literature is cited to support the thesis and conclusions.

"If we could raise one generation of children with unconditional love, there would be no Hitlers."

Elizabeth Kubler-Ross (Phillips, 1991, p.11)

INTRODUCTION

The thesis of this paper derives from the conviction that the essence of psychotherapy is a relationship characterized by empathy, respect or compassion, and therapeutic genuineness (See Rogers, 1957). This relationship is best characterized by agape, or love. The consistent loving, caring relationship has long been identified with client-centered therapy.

That the basis of psychotherapy is love has been recognized by many writers. Gordon Allport (1950) nearly 50 years ago, wrote: "Love is incomparably the greatest psychotherapeutic agent" (p. 80). Thirty years ago Arthur Burton wrote: "After all research on psychotherapy is accounted for, psychotherapy still resolves itself into a relationship best subsumed by the word love" (Burton, 1967, pp. 102-103). The object relations theorists Guntrip (1953) and Fairbairn (1954) used the word agape to summarize the therapy relationship: "This kind of parental love . . . agape . . . is the kind of love the psycho-analyst and psychotherapist must give the patient because he did not get it from his parents in sufficient measure or in a satisfactory form" (Guntrip, 1953, p. 125). Patterson (1970,1974) independently began using the term agape to summarize the therapy relationship.

If the source of psychosocial emotional disorders is the absence or lack of love, and if love is the cure for such disorders, then it follows that the primary prevention of such disorders would be the providing of unconditional love to all infants and children. The conditions for successful psychotherapy are the conditions for normal infant, and human development.

LOVE AND ITS DEPRIVATION IN INFANCY

While love is important throughout life for the well-being of the individual, it is particularly important, indeed absolutely necessary, for the survival of the infant, and for providing the basis for the normal psychological development of the individual. The presence of at least one caregiver providing unconditional love for every infant (and young child) will prevent the occurrence of most social-psychological pathology. References are cited later to support this premise. Pathology deriving from neurological or biochemical sources would not be included. Burton (1972), while discouraging the search for a single overriding trauma causing emotional disturbance, nevertheless states that "the basic pathogen is, for me, a disordered maternal or caretaking environment rather than any specific trauma as such" (p. 14). Disruptive behaviors related to the influence of peer pressures would decrease and eventually disappear, since peers would (1) be less likely to be disturbed and (2) their influence would be reduced or eliminated since their peers would be secure and not vulnerable to such pressure. Other than neurological and biochemical disorders (some of which might be genetically based), such disruptive behaviors as existed would derive from the deprivation of the biological needs for existence; frustration of such needs could lead to aggressive and antisocial behaviors. But in a society permeated by love, such needs would be met - where there is love there will be bread.

We define love as an attitude that is expressed through empathic understanding, respect and compassion, acceptance, and therapeutic genuineness, or honesty and openness toward others. In more personal - as distinguished from therapy - relationships, love may be defined as "that which satisfies our need to receive and bestow affection and nurturance; to give and be given assurance of value, respect, acceptance, and appreciation; and to feel secure in our unity with, and belonging to a particular family, as well as the human family" (Walsh, 1991, p. 9).

EARLY RECOGNITION OF IMPORTANCE OF INFANT AND EARLY CHILDHOOD INFLUENCES

A hundred years ago Freud emphasized the importance of infancy and early childhood on later development and psychological disturbance. Early on he attributed neuroses to the early trauma of being sexually molested. But a few years later he changed his views, concluding that it was not actual sexual experiences of seduction, but false memories and fantasies that were the cause (the Oedipal complex). Attention to the importance of real experiences of the infant and child was thus deflected to unreal or imagined experiences.

The object relations school of psychotherapy emphasizes the importance of the infant's and child's relationship with a primary care person: "whatever a baby's genetic endowment, the mother's ability or failure to 'relate' is the sine qua non of psychic help for the infant. To find a good parent at the start is the basis of psychic health" (Guntrip, 1975, p. 156).

During the 1940's several psychoanalytic therapists published reports of the effects of real experiences on children. The term maternal deprivation was applied to these experiences. In 1937 Levy (1937) published a study of children separated from their mothers at an early age. Lauretta Bender and Stella Chess, working in the child psychiatric service at Belleview Hospital in New York reported on children who experienced emotional deprivation during their early years (Karen, 1994; Bender and Yarnell, 1941).

Children in hospitals, even for brief periods of separation from their mothers, and children in institutions were found to be psychologically disturbed (Bakwin, 1942; Bowlby, 1959, 1973). In 1945 Rene Spitz (1945, 1946) reported on his experience with children in a foundling home, comparing them with children in the nursery of a penal institution. The physical conditions in the foundling home were better then those in the penal institution, but the illness and death rates were higher. Although developmentally the foundling home infants were superior, after a year of institutionalization they were inferior to those in the prison setting. Within two years, 37 percent of the foundling home children were dead; all the prison children were alive five years later. The difference between the two settings was that in the prison the children's mothers cared for them, while in the foundling home the children were cared for by professional nurses.

John Bowlby became interested in the influence of the early environment in children in the late 1930's, and published his first paper in 1940 (Bowlby, 1940). In 1944 he published a paper reporting on 44 children, ages six to sixteen who were young thieves (Bowlby, 1944). The mothers of these children were described by social workers as "immoral, violent and nagging," "extremely anxious, fussing, critical," " drunken and cruel," "did not want the child," "unstable and jealous," etc. One common objective factor was prolonged early separations of the child and mother, separations where the child had never developed a true attachment, and after separation had no opportunity to develop a true attachment.

In a study conducted for the World Health Organization, Bowlby (1951) surveyed the field and earlier studies. This survey included the work of Dorothy Burlingham and Anna Freud (1944) with children evacuated from London during the war whose behavior deteriorated in the absence of their mothers. Bowlby's survey showed that the behaviors and psychological disturbances of children subject to maternal depravation and separation were many and varied. In addition to the thievery observed by Bowlby, these disturbances included: indifference, incorrigibility, hostility, lack of any feeling or empathy for others - affectionless and detached (characteristic of a psychopathic personality).

The conditions leading to such behaviors, in addition to early, even brief, and later, longer separation from the mother, include lack of or early loss of mother-love, and the emotional quality of the home, even before the child's birth. Bowlsby referred to the British style of parenting - cold, impatient, demanding. But such an atmosphere of child rearing was not limited to Britain. For much of the first half of this century child rearing in the United States followed Watson's (1928) approach:

Treat them as though they were young adults. Dress them, bathe them with care and circumspection. Let your behavior always be objective and kindly firm. Never hug and kiss them, never let them sit on your lap. If you must, kiss them once on the forehead when they say goodnight. Shake hands with them in the morning. Give them a pat on the head if they have made an extraordinary good job of a difficult task (pp. 81-82).

Of course not all, or even most, mothers and fathers followed the British and Watson precepts - fortunately so, considering the effects of such a program. The need for love in the normal development of infants and children would appear to be obvious.

The human infant is helpless and obviously unable to meet its needs for food, clothing, and shelter. In addition to the meeting of these needs, the infant needs more. It needs a nurturing, caring, compassionate caretaker who provides love. For the infant, love is communicated primarily through touch - stroking, cuddling, massaging, kissing. Walsh (1991) notes that "even the behaviorist John Watson believed that love was an innate human emotional need that is fed by the tactile stimulation an infant receives as it snuggles in its mother's arms" (p. 12). This care is "neurologically critical during the sensitive period in which the neural pathways are being laid down" (Walsh, 1991, p. 44). Somatosensory deprivation - lack of touch, movement, massage, etc. - appears to be a basic cause of many physical and psychological disturbances.

Barry Stevens (Rogers and Stevens, 1967) writes about an incident when her husband was in charge of a pediatric ward in a New York hospital in the twenties. "There was an infant whom none of the doctors could find anything wrong with, but all of them agreed the infant was dying. My husband spoke privately to a young nurse who loved babies. He swore her to secrecy before telling her what he wanted her to do. The secret was, 'Take care of this baby as if it were your own. Just love it.' At that time love was nonsense even to psychologists . . . .The baby took hold. All the doctors agreed on that" (p. 31).

Recently a number of hospitals have been conducting experiments with hospitalized infants. Walsh (1991) refers to an AP news story (Associated Press, 1988) that reported on a volunteer program at St. Lukes'-Roosevelt Medical Center in New York, that takes abandoned, neglected infants and those born drug-addicted or with AIDS. Although given good physical care, they received no touching or stimulation, lying listless, and in time not even reacting to sound. But, when volunteers held them, stroked, and cuddled them they became alert, smiling, cooing, and reacting to stimuli.

At the University of Miami Medical School, psychologist Tiffany Field conducted an extensive study of premature infants (Ackerman, 1990). The infants were stroked and massaged by nurses and volunteers three times daily. The massaged infants gained weight faster, became more active and alert, were more responsive to stimuli, and were discharged from the hospital sooner than nonmassaged infants. Follow-up found that the massaged infants were larger and had fewer physical problems. They also did better in tests of mental and motor ability. Touch is a powerful expression of caring. Deprivation of this caring results in retarded physical and psychological development.

Walsh (1991) writes that there is a growing momentum among anthropologists, endocrinologists, physiologists, psychiatrists, psychologists, neuropsychologists, and others, to recognize the role of mothers in "the critical task of humanizing the species . . . modern neurophysiology is reaffirming Freud's belief in the centrality of the mother's role in making us human . . . .love . . . is a biological and psychological necessity" (p. 37).

It is important to note that unloving behavior such as aggressive physical and verbal behavior toward children is disruptive of healthy development (Cohen & Brook, 1995). Hitting, slapping, beating, and yelling even when justified as punishment have a causal effect on the development of delinquency through modeling coercive and aggressive behavior (McCord, 1995). Children learn the very interpersonal behaviors which the punishment is usually designed to supress (Cohen and Brook, 1995). Caretaker behavior need not be extreme to cause behavior disorders. According to Maughan, Pickles, and Ouinton (1995) "Harsh and coercive parenting, even when it falls short of overt abuse, can have serious negative effects" (p. 34). The use of sarcasm ("I'm gonna break your legs if you don't settle down."), scare tactics ("Stop that or I will lock you in the attic with the ghosts."), belittling the child ("You're so stupid."), or labeling and rejecting the entire child for one act ("You are a bad boy for running across the street.") can have detrimental effects on the healthy development of children (Cochrane and Myers, 1980). Baumrind (1980), evaluating the research, concludes that "caretakers play a determining role in the ways their children develop . . . .caretakers can have a determining effect on children's intelligence, character, and competence" (p. 640).

Ainsworth (1979) who with Bowlsby spent much of her life studying mother-infant attachment, notes that while "it is an essential part of the growth plan of the human species - as well as that of many other species - for an infant to become attached to a mother figure, this figure need not be the natural mother but can be anyone who plays the role of principal caregiver" (p. 932).

Baumrind (1980) states that "there is no evidence of a biological need for an exclusive primary bond, and certainly not a bond to a particular person because she happens to be the child's biological mother" (p. 145). But "a primary commitment cannot be shared, although the care itself can and should be. Someone must, when no one else will, provide the attention, stimulation, and continuous personal relationship without which a child is consigned to psychosis, psychopathy, or marasmus" (p. 145). And fathers, men, can be principal caregivers, especially if they are socialized to give appropriate nurturing behaviors.

CONSEQUENCES OF LOVE DEPRIVATION

The effects of being deprived of love are harmful to adults and devastating to children. "Individuals deprived of love become emotionally barren as they plod through dark lives" (Walsh, 1991, p. 8). "Without love there can be no healthy growth or development" (Montagu, 1981, p. 93).

Walsh (1991) opens his discussion of the effects of absence of a loving infant and early childhood environment with a general statement: "The human infant can be molded and cultivated into a decent and caring adult, or its development can be distorted horribly in a way no nonhuman animal can have its nature altered by experiences that occur within its species" (p. 8). He then proceeds to document this statement. The innate potentials of the infant or child, the inherent drive towards the actualization of these potentials in a process of self-actualization, can be inhibited and distorted by the absence of a nurturing environment of unconditional love. Furthermore, these human potentials can be nearly or totally destroyed by abuse of the caretaking relationship.

The Neuroses

The various neuroses originate in some form of emotional deprivation, resulting in a lack of satisfaction of the basic human needs for affection, security, respect, and self-esteem. The child's need for love has been thwarted by parents who are emotionally cold, controlling, and unloving. The neurotic engages in attempts to meet his or her needs for love and respect in ways that often turn other people off. Neurotics are unable to offer the love and respect which would lead to reciprocation by others. Henderson (1982) studied the neurotic person's difficulty of forming attachments. Though they desperately desire such attachments, and engage in care-eliciting behavior, involving crying (in children), attempts to draw sympathy and "please love me" appeals, this behavior is not successful. Walsh (1991) relates this to Maslow's deficit love, an abnormal craving for love.

Depression and Suicide

One of the symptoms of depression is thoughts of suicide. However, depression itself is an amorphous category of emotional disturbance. What has been called marasmus in infants is probably similar to depression in older persons. While there appears to be an increasing awareness of biochemical, and even genetic factors in depression, it is still the case that depression is usually precipitated by environmental events, particularly the loss of a loved one. And it is possible that biochemical abnormalities are the result of psychosocial experiences. Akiskal and McKinney (1975), for example, suggest that rejection, lovelessness, and lack of relatedness leads to reduced brain catecholines resulting in the behavioral disturbances characteristic of depression. Certainly, there are depressions that are the result of psychosocial factors rather than biochemical or genetic factors, though a genetic predisposition may be present in some cases. The evidence, at this time, is not consistent or absolutely definitive.

Suicide appears to be clearly related to psychosocial factors. Durkheim (1951), a French sociologist, noted the relation between social anomie and suicide. Suicide is higher in urban areas, among the unmarried and divorced, and among those living isolated lives. Among children, those who attempt suicide are more likely to have experienced abuse and neglect (Rosenthal and Rosenthal, 1984). Adolescents who attempt suicide are usually isolated from their friends and family. Walsh (1991) reports a study in which he and a colleague found suicide attempts among juvenile delinquents related to love-deprivation.

Schizophrenia

As in the case of depression, there is evidence of brain malfunctioning and genetic factors in many of those diagnosed as schizophrenic. But there are wide differences among those with this diagnosis. While the concept of schizophrenogenic mother is no longer accepted, there are psychosocial factors present; it is difficult, however, to discern cause-effect relationships, even though PET and CAT scans show brain abnormalities. Drugs (chlorpromazine and recently clozapine) relieve or remove the symptoms in many schizophrenics.

Seymour Kety (See Walsh, 1991), a researcher on the genetics of schizophrenia, points out that we cannot dismiss environmental factors which can precipitate, intensify, or ameliorate symptoms. Love deprivation is viewed by many as an environmental factor, that may operate by affecting chemical factors in the brain. Walsh (1991) cites studies by Robert Heath on Harlow's love-deprived monkeys that found brain disturbances. Walsh concludes that "schizophrenia may very well be the result of the effects of early childhood experiences on the mechanisms of neurotransmitter metabolism for individuals with a schizophrenic predisposition" (p. 124). Lack of care and parental love, experienced as coldness and rejection, lead to passivity, isolation and suspicion (Buss, 1966). Studies of the onset of schizophrenia find this isolation and lack of responsiveness prior to the onset. Walsh (1991) points out that genetic factors in parents may influence parenting behavior. In addition, the authors note that some attention should be given to historical psychosocial factors in parental behavior. What quality of caretaking experience did the parents have themselves as children and how did that experience influence the parents' ability to love their children? The interactions of genetics, brain chemistry and environmental factors are complex, but in the trend toward biologizing schizophrenia, environmental factors cannot be ignored.

Sociopathy and Criminality

Statements reminding us of the importance of early love in antisocial behavior abound. A Public Broadcasting System radio program recently quoted a former Los Angeles gang member as saying: "Kids aren't born bad. Kids are bad because they can't find love." Anthropologist Ashley Montague (1970) writes: "Show me a murderer, a hardened criminal, a juvenile delinquent, a psychopath, or a 'cold fish' and in almost every case I will show you a tragedy that has resulted from not being properly loved during childhood" (p. 46). Research cited by McCord (1995) point to aggresive parental behaviors such as hitting, slapping, and beating as contributors to the development of juvenile delinquency. Lance Morrow (1992), in a Time magazine essay came to the conclusion that "it is usually the want of love that makes children vicious and sends them out of control" (p. 68).

Not all criminal behavior is the result of lack of love, of course. Walsh (1991) estimates that about ten percent of habitual criminals are psychopaths, or sociopaths. They come from loveless homes, characterized by neglect, rejection, and abuse. Not having experienced love for themselves, they may have difficulty feeling love for others. In some cases, children have had to alienate themselves from their own hurt at being unloved, from their feelings of unworthiness and eventually self-rejection. To protect themselves from the those negative feelings, they have alienated themselves to some degree from all feelings. Thus they have a diminished capacity to feel sympathy or empathy for others, and are able to engage in cruelty toward others without personally feeling consequences. They have little or no capacity for empathy.

Empathic development always occurs through interaction with others. Hoffman (1982) outlined developmental progression of empathic awareness beginning at birth with a reactive cry. This is a response when newborn babies hear the cry of other babies. The ability to take the role of another, according to Hoffman, begins around the age of 2 or 3 when a child can understand that others have feelings which differ from his/her own. Another step toward empathic potential comes with the development of language. Although there is probably no one critical window of time for development of empathy, it would be reasonable to predict that a child who does not experience being loved would have few experiences for positive identification of self and others, and would be less likely to develop the capacity for empathy. Aggression, violence and cruelty may be committed without limits when there is no development of empathic understanding with others.

Walsh (1991, pp. 141-146) presents evidence that deprivation of love affects the functioning of emotional centers of the brain, leading to disruptive behaviors. "In fact, the physiological line of thought reasons that socialization and the development of conscience (the internalized control of behavior) are largely a function of autonomic conditioning in childhood" (Walsh, 1991, p. 147). That early experiences can affect brain structure as well as function is becoming clear. Weil (1985) notes "that experiences induce neurophysiological structuring is increasingly recognized" (p. 336; see also Rourke, Bakker, Fiske, and Strang, 1983). Whatever the interrelationships and relative weights of genetic, neurological, and psychological factors, sociopathic criminals appear to share some abnormalities in all these areas; genetic factors contribute susceptibility to the influence of other factors.

Not all parents are good nurturers, or to use Winnicott's (1965) term "good enough mothers." Not all parents can or will love their infants. But it is not possible to remove infants or children from such parents, unless and until there is evidence of abuse. Early intervention, beginning before the birth of the child can have positive effects with some of these parents. Intervention later to repair the effects of neglect and abuse has not been highly effective (Parens and Kramer, 1993). It is possible that there is a critical period for the bonding of the necessary relationship with a caretaker.

WHAT CAN BE DONE?

Ideally, every infant and young child should have at least one principal caretaker who can and will provide the unconditional love necessary for normal physical and psychological development. This is clearly a tremendous task, and society is probably not yet ready , or able, to provide such care. Yet while it may be impossible in our world society to assure a loving caregiver for every infant and child, the desirability, indeed the necessity, of doing so must be recognized, and steps taken toward its achievement. Walsh (1991) notes that while there are agencies charged with assuring a minimal level of food and shelter (though not successfully doing this for all citizens), "there are no similar institutions monitoring the nation's love needs, nor is there likely to be any time soon" (p. 52).

Steps that can, and should be taken include the following:

0. Ratification by the United States of the United Nations Convention on the Rights of the Child (United Nations General Assembly, 1989). This convention was adopted by the159 Member States of the UN General Assembly on November 20, 1989, and has been ratified by 54 nations, but not by the United States. This convention includes the right of the child to affection, love, and understanding in a family, unless it is in the best interests of the child to remove the child from the parents.
1. Prenatal care, including preventing malnutrition in mothers, and education in infant needs and care can be increased. Here, the United States is behind some other countries.
2. Modification of hospital practices and extension of the programs to provide infant stimulation through massaging and other contacts by touch, by the mother/father and by other hospital personnel.
3. Providing maternal - and paternal - leave from employment on, and for a period following, the birth of a child. Desirably this should be paid leave, so that those with low incomes could afford it. The United States has lagged behind other countries. Over 100 countries provided this, before the United States, even though the United States was a signatory to the United Nations Convention in the Elimination of all Forms of Discrimination Against Women that includes an agreement "to introduce maternity leave with pay or comparable social benefits without loss of former employment" (Walsh, 1991, p. 53). In 1993, the United States finally joined the other developed countries when the family leave legislation was passed by the Congress and signed by President Clinton.
4. Provide person-centered theory based education to parents and potential parents about effective parenting behavior and the provision of love.
5. Provide education to the public concerning the devastation of abuse. Part of the problem of abuse is that the issue has been avoided. From the time when Sigmund Freud bowed to the pressure of professional shunning to our own times when abuse is still denied as fantasy, human abuse reminds us too poignantly of our own fears. In avoiding our own sorrow we have allowed children to live the terror of abuse and to pass their inheritance to the following generations.
6. Encourage the awareness of the media (television/video programming, print and internet) as influences on interpersonal behavior, especially on modeling effective behavior for parenting roles, conflict resolution, and the provision of love.

CONCLUSION

This paper presents just a sampling of the voluminous evidence that the level of love in infancy and early childhood is the source of much, if not most, psychosocial disturbance and disorder Love is a powerful prophylactic. The logical solution of the problem is startlingly simple: The provision of a safe and loving caregiver for every infant and child. The actual implementation of this solution is admittedly difficult. It requires focus and intent. Educational models built on client-centered/person-centered theory can contribute to healthy social roles and behaviors which promote more effective love of children. Therapists can facilitate person-centered theory based education through school and college classes, organizational presentations, and community discussions. There are isolated efforts being made toward the goal of creating more loving environments for children, and thus there is some hope that with recognition of its importance, more will be done.

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Author Note: Chapter adapted from Successful Psychotherapy: A Loving, Caring Relationship (1997). C. H. Patterson & S. C. Hidore, New York: Jason-Aronson.